Painful peripheral neuritis. Loss of support at the medial

Painful symptoms accompanying
flexible flatfoot include, a wide distribution of pain and an increase in
fatigue rate in lower limb area, osteoarthritis, achilles tendinopathy and
patellofemoral disorders may appear. Other signs observed include the abnormal
appearance of rearfoot kinematics such as a rearfoot excessive eversion or by
an increase in the eversion range, abnormal kinetics of the foot and ankle such
as joint moments elevated or loading forces abnormal values and change in the
physical function by abnormal timing and activation of muscles or by raising consumption
of energy. These functional consequences are the reason for the symptomatic
flexible flatfoot, and the intervention should target these abnormalities.(Banwell et al., 2014)

In adult acquired ?atfoot, the deformity
is due to arthritic changes, neuromuscular diseases, and traumatic conditions.
While the most common deformity cause remains posterior tibial tendon
dysfunction, many conditions could cause the tendon dysfunction such as rupture
and secondary arthritis which is considered the most severe sequelae, in the U.S.
about 5 million people are affected by this condition.(Abousayed et al., 2016)

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Adult acquired flatfoot can be
caused by many conditions such as, ankle degeneration changes that happen in
the tarsometatarsal or talonavicular or both, these degenerations occur
secondary to fractures, inflammatory arthropathy and Osteoarthropathy. the Neuropathic
foot that occur secondary to leprosy, diabetes mellitus and profound peripheral
neuritis. Loss of support at the medial longitudinal arch seen in tibialis
posterior tendon dysfunction or calcaneoanvicular ligament tear. Other
conditions for painful flatfoot may include tarsal coalition. Risk factors
include middle-aged women, hypertension, diabetes mellitus, injecting the area
around the tendon with steroid, and seronegative arthropathies. These factors
are observed in the tibialis posterior tendon insufficiency condition.(Kohls-Gatzoulis et al., 2004)

In flexible flatfoot etiopathology
this study indicated, while the normal medial longitudinal arch of the foot is
formed by the foot bones which are supported by ligaments, tendon and capsular
structures, the medial longitudinal arch is not preserved by the foot muscles.
The electromyographic study resulted in that intrinsic and extrinsic muscles
didn’t help in supporting or maintain the medial longitudinal arch while
assuming a standing position (Basmajian and Stecko, 1963). although during walking the dynamic stabilization of the arch is
maintained by both muscle groups, this argument is reinforced by a study that
resulted in that intrinsic muscles of the foot have an important role in
supporting the medial longitudinal arch (Fiolkowski et al., 2003). In the posterior tibial tendon insufficiency flatfoot, it has
been suggested the musculature importance, as indicated in a study which
resulted that the most significant anatomical structure is the plantar fascia
due to its role in stability of the medial arch, along with the talonavicular,
and spring ligaments.(Huang et al., 1993)

In adult, flexible flatfoot may
appear bilateral or unilateral, the main symptoms are pain at arch, heel, and
the foot lateral aspect, these symptoms are aggravated by activities that
include weight bearing such as running, walking, and hiking. Orthotics is
considered to be an early treatment option for this condition(Lee et al., 2005), its designed to stabilize and realign the foot arch, symptoms
relief is a noticeable success in patient.(Chen et al., 2010)

In a search of the biomechanical effects of wearing foot
orthotics on medial longitudinal arch in patient with flexible flatfoot from
the literature, one study compared between the effect of short foot exercises
and the use of insoles on the medial arch, in the orthotic group the orthotic was made to affect the
medial arch height (value of 20° and a height of at least 15 mm) and was
standard for all patient. The parameters assessed was measuring the changes in
the height of the medial longitudinal arch, which resulted in that short foot
exercises are more effective and insole changes in the medial longitudinal arch
were not significant. The limitation of this study includes the sample size was
small 14 (males 10, females 4), the period of the intervention is short (six
weeks) which is not sufficient for insoles to make an effect on the medial arch
or evaluate long-term effect. (Kim and Kim, 2016)

While in this study they evaluated
the effect of orthotics in different walking conditions, it was conducted for 3
months, the shoe and orthotics were
standard for all patients, the orthotic measurement was (thickness arch 2.6 cm,
and the thickness of fore foot and heel was 0.4 cm), the parameters assessed
were the load rate and contact
area from planter pressure, the study resulted in an increase in the height of
foot arch and there was a change from midfoot in weight-bearing to heel and
fore foot, which lead to decrease in the midfoot contact area and load rate.
The correction of planter pressure was found in horizontal ground and in
walking up and down stairs. The limitations include the sample size was small 15, they didn’t measure the changes
in the arch height.(Zhai et al., 2016)

Another
study compared the prefabricated and proprioceptive foot orthoses effect during
walking on the distribution of plantar pressure, in
the prefabricated orthotic
group the orthotic supported the
longitudinal arch and was 1-mm-thick while the proprioceptive orthotic group the
orthotic was a flat with no arch support. The parameters assessed were peak pressure, maximum force, and
contact area, it resulted in the prefabricated insole there was no major
differences in contact area, while a significant decrease in peak pressure and
force was noted, this reduction of the heel pressure is due to structural
mechanisms of supporting the medial arch that lead to load transfer into
midfoot area and in realigning the calcaneus to be in a normal position, thus
leading to changes in pressure distribution. The limitations include the
sample size is small 12 and they
were male only, they assessed it in walking condition, the study didn’t evaluate
long-term effect.(Aminian et al., 2013)

Masamitsu Kidoa study evaluated the
load response in medial arch to assess the effectiveness of the insoles in supporting
the medial arch, they used two types of insoles accessory insoles and therapeutic
insole which raised the arch by 10 mm with a 5-mm inner wedge, the parameters
assessed include the load response, it resulted in that it was significant that
the therapeutic insole suppressed talocalcaneal joint eversion compered to the
accessory insole, limitations
include the sample size is small 8 (males 4, females 4), they assessed it in mimicking a standing condition, the study didn’t
evaluate long term effect.

In Hassan Saeedi study, they
evaluated the effect of a customized orthoses done by University of California
Berkeley Laboratory and its impact on muscle activity and kinetic, the parameters
assessed were Foot skeletal alignment, visual analog scale, muscle activity
(tibialis anterior, peroneus longus and medial gastrocnemius), ground reaction
force. The study resulted in there was a correction in the alignment of the foot,
the VAS results were reduced, the foot is functioning with a less load on the
soft tissue, the limitations
include they only used one subject in the study, it was for one month hence
no long-term effect can be given.(Saeedi et al., 2014)

After reviewing these study results
in the matter of orthosis effect on the medial arch, we can observe that there
is a need in increasing the sample number, and in investigating the long-term
effect of orthosis and measurement of the arch height which leads to the
conclusion of the medial arch in flexible flatfoot to be realigned.